Medicaid advocates raise concern over prior authorization denials in managed care plans

Bloomberg Law  (7/25, Belloni, Subscription Publication) reports, “Medicaid advocates are sounding the alarm over systemic oversight failures and misaligned incentives that allow Medicaid managed care companies to restrict patient access to health care services.” The Department of Health and Human Services Office of Inspector General “ found that 37 states it surveyed had systemic problems with their prior authorization processes, leading to inappropriate denials of coverage.” Among the issues were failing to let Medicaid patients know about “their right to appeal a denial, allowing insufficiently trained staff to make prior authorization decisions, and writing notices in ambiguous, often hard-to-understand language that missed or concealed important information such as the reason for a rejection.”

Below is the Florida specific denial rates for the Medicaid Managed Care Plans according the DHS OIG Study.   In Florida, Medicaid Beneficiaries are auto assigned to a Managed Care Company in their region.  Evidently for Medicaid Beneficiaries, their assignment becomes a lottery as to their likelihood of getting the care they need.